Sertraline Can Cause Suicidal Ideation in Children and Adolescents
Yes, sertraline can increase suicidal ideation in children and adolescents, particularly during the first few months of treatment or when doses are changed, though the absolute risk is small and must be weighed against the risks of untreated depression.
FDA Black Box Warning
The FDA issued a black box warning specifically addressing this risk 1. All pediatric patients treated with sertraline must be observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of treatment or at times of dose changes 1. Notably, sertraline is NOT FDA-approved for treating depression in children and adolescents—only for obsessive-compulsive disorder in this age group 1.
Quantifying the Risk
The evidence shows:
- Meta-analyses demonstrate SSRIs, including sertraline, are associated with increased risk of nonfatal suicide attempts (odds ratio 1.57-2.25) compared to placebo 2
- A 2025 systematic review found SSRIs increase treatment-emergent suicidality, particularly during early treatment phases 3
- The most recent 2026 meta-analysis specifically examining anxiety disorders found SSRIs/SNRIs showed a 3.51-fold higher risk of suicidal ideation compared to placebo 4
However, a 2006 meta-analysis found no statistically significant difference in suicidal behavior between SSRIs and placebo when examining depression trials specifically 5.
Clinical Context: Risk vs. Benefit
Despite the increased suicidality risk, sertraline remains indicated for severe depression in adolescents when psychotherapy alone is inadequate 6. The 2018 GLAD-PC guidelines recommend sertraline as a treatment option with specific dosing: start at 25mg daily, increase by 12.5-25mg increments, with effective dose of 50mg and maximum of 200mg 6.
Critical Monitoring Requirements
Contact (in-person or telephone) must occur after treatment initiation to review adherence and current status 6. Watch for these specific warning signs 1:
- New or sudden changes in mood, behavior, actions, thoughts, or feelings
- Acting on dangerous impulses or aggressive behavior
- Increased agitation, restlessness, anger, or irritability
- Trouble sleeping or increased activity/talking
- Attempts to commit suicide or thoughts about suicide or dying
Important Caveat About Dosing
Deliberate self-harm and suicide risk are MORE likely if sertraline is started at higher doses rather than normal starting doses 6. Always begin at 25mg daily in adolescents.
Combination Therapy Reduces Risk
Multiple studies show that combining sertraline with cognitive behavioral therapy (CBT) yields better outcomes and lower rates of suicidality compared to medication alone 3. When prescribing sertraline for adolescent depression, concurrent psychotherapy should be strongly recommended.
The Untreated Depression Risk
The guidelines emphasize that depression itself is associated with increased suicide risk, and this must be balanced against medication risks 1. The decision to use sertraline requires weighing the small but measurable increase in suicidal ideation against the substantial risks of untreated major depressive disorder.